Bone mineral content in young adults with active or inactive juvenile idiopathic arthritis and in controls.

OBJECTIVE: To obtain information on bone mineral content (BMC) in juvenile idiopathic arthritis (JIA) in young adulthood. METHODS: BMC measurements of 116 young adults with JIA and controls were performed at the lumbar spine and the proximal femur by dual-energy X-ray absorptiometry (DXA). RESULTS: Patients were divided into the JIA-active group (n = 73) and the JIA-inactive group (n = 43). Fifty-five per cent of men and 30% of women had their disease in remission. Forty-eight per cent in the JIA-active group and 16% in the JIA-inactive group had used glucocorticoids (p < 0.001). Mean BMC in the femoral neck was 5.76 (SD 0.21) g for men and 4.74 (SD 0.10) g for women in the JIA-active group; 5.84 (SD 0.23) g for men and 4.59 (SD 0.06) g for women in the JIA-inactive group; and 6.65 (SD 0.20) g for men and 4.78 (SD 0.07) g for women in the controls. Both JIA groups had lower BMC values in the femoral neck than the controls (p < 0.001), but a statistically significant difference was found among men (p = 0.006). There was no significant difference in mean BMC in the lumbar spine between the JIA groups and the controls, nor between men and women. Glucocorticoid use, weight and also height among women were associated statistically significantly with BMC in the femoral neck. CONCLUSIONS: Young adults, especially men, with JIA have reduced BMC values in the femoral neck. Glucocorticoid use and weight, but not disease activity, seem to be associated with lower BMC. However, osteoporosis is rare.

Uveitis in young adults with juvenile idiopathic arthritis: a clinical evaluation of 123 patients.

OBJECTIVE: To examine the prevalence and characteristics of uveitis in young adults with juvenile idiopathic arthritis (JIA). METHODS: The study population consisted of 123 JIA patients born between 1976 and 1980 whose arthritis had been diagnosed and treatment first started at the Rheumatism Foundation Hospital in 1976 to 1995. A clinical re-evaluation was carried out by an ophthalmologist and a paediatric rheumatologist 16 years later on average. RESULTS: The mean age of the patients was 23.5 years, 72% were women, and 63% had oligoarthritis. During the course of the disease, diagnosis of uveitis had been made in 25 patients (20%). Arthritis in the 19 patients with asymptomatic uveitis was more often ongoing than in the 98 patients without uveitis (p = 0.032). Asymptomatic uveitis was persistent in eight of the 19 cases (42%), and arthritis was active in seven of these. Four of the six patients with attacks of symptomatic uveitis had parallel treatment for arthritis. In three of 19 patients with asymptomatic uveitis and in five of six with acute uveitis the eye inflammation had started after the age of 16. At the onset of arthritis the patients with asymptomatic uveitis were younger than those without uveitis (p = 0.002). Complications of uveitis developed in six patients but their sight remained good. CONCLUSIONS: Asymptomatic uveitis continued into adulthood in almost half the uveitis patients. Most also had ongoing arthritis. Acute uveitis was often associated with persistent arthritis.

Favourable social functioning and health related quality of life of patients with JIA in early adulthood.

OBJECTIVE: To evaluate the social functioning and health related quality of life (HRQoL) in patients with juvenile idiopathic arthritis (JIA) in early adulthood. METHODS: The patient files of the Rheumatism Foundation Hospital were screened to identify patients born in 1976-1980 diagnosed as having JIA. HRQoL was measured by the RAND 36-item health survey 1.0; spousal relationships and educational and employment status were assessed by questionnaire. The patients were invited to a follow up study. Age and sex matched controls from the community were identified in the Finnish population registry. RESULTS: Of 187 patients identified, 123 participated. Spousal relationships, educational level, and employment status were similar to controls. HRQoL in JIA patients was similar to controls except on the physical functioning scale. At follow up 35% of patients were in remission. Patients with active disease had poorer HRQoL in the physical component than those in remission or controls. The extended oligoarthritis group had the lowest physical and mental score in HRQoL compared with the other JIA subgroups. The patient's own evaluation was the explanatory factor in both the physical and mental component of HRQoL. CONCLUSION: Social functioning and HRQoL were similar in JIA patients and age, sex, and municipality matched controls. However, patients with extended oligoarthritis attained significantly lower scores in the physical and mental component of HRQoL than oligo- or polyarthritis patients. Special attention in everyday care should be paid to those patients who have active disease or the extended oligoarthritis type of disease.

Good results from combining etanercept to prevailing DMARD therapy in refractory juvenile idiopathic arthritis.

OBJECTIVE: To assess the effect of etanercept added to prevailing drug therapy in patients with juvenile idiopathic arthritis (JIA) whose disease was refractory to conventional disease-modifying antirheumatic drug (DMARD) treatment, including combinations of different DMARDs. METHODS: Data on 31 JIA patients with a disease resistant to conventional DMARD treatment were retrospectively collected from medical records and assessed for a one-year period after the introduction of etanercept or to the time of cessation of the drug due to a lack of efficacy or side effects. Efficacy was assessed based on the normal laboratory indexes of inflammation and changes in the following parametres: number of DMARDs used and intraarticular (i.a.) glucocorticoid injections. The numbers of inpatient days needed were also recorded. RESULTS: Etanercept was well tolerated. Only two patients stopped discontinued the treatment because of allergic rash, after 3 weeks of treatment in one case and after 4 months in another. In two cases the treatment was discontinued because of a lack of efficacy. During the treatment, there was a significant decrease in the number of DMARDs used and the i.a. glucocorticoid injections needed as well as in the dose of per oral glucocorticoids. The laboratory parameters also improved. In addition, there was a significant decrease in the number of inpatient days per 3-month period before and during the etanercept treatment. CONCLUSION: The addition of etanercept to conventional DMARD therapy in children with the most severe cases of JIA leads to an excellent clinical response during the first 12 months. The tolerability of the drug is good in combination therapy with various DMARDs.

Persistence of parvovirus B19 DNA in synovial membranes of young patients with and without chronic arthropathy.

BACKGROUND: Human parvovirus B19 replicates in erythroid precursors of the bone marrow, and several diseases have been attributed to this virus including some cases of juvenile chronic arthropathy. METHODS: Tissue samples from children with juvenile arthritis and from healthy young adults with recent joint trauma were examined for B19 DNA by PCR. We also studied the timing of the parvovirus infection serologically. FINDINGS: All samples of synovial fluid, bone marrow, and blood were negative for B19 DNA. Eight (28%) of the 29 children with chronic arthritis had B19 DNA in synovial tissues. However, an even higher proportion of the non-arthropathy controls were positive for B19 DNA in synovial membranes (13 [48%] of 27). All the individuals with B19 DNA in synovial membrane had serum IgG antibodies to B19. INTERPRETATION: Genomic B19 DNA can persist in the synovial membranes not only in patients with chronic arthropathy but also in healthy immunocompetent individuals. The diagnostic criteria for parvovirus arthropathy must be reevaluated.

Synovial fluid lymphocytes in different subtypes of juvenile rheumatoid arthritis.

We studied the subsets of synovial fluid (SF) lymphocytes and their activation states in 4 subtypes of juvenile rheumatoid arthritis. The expression of lymphocyte differentiation antigens and activation markers (Ia and Tac) appeared to be similar in these subgroups. Tac + DNA-synthesizing T blasts represented, at most, 5% of all SF mononuclear cells. This finding was in clear contrast to the high proportion of Ia-positive SF mononuclear cells. There were no differences in Ia and Tac expression or DNA synthesis among the different juvenile rheumatoid arthritis subgroups. This finding suggests that the cell-mediated immune response may represent secondary features of the disease that are involved as a final common pathogenetic pathway.

Arthritis caused by Haemophilus paraphrophilus and isolation of the organism by using an improved culture protocol.

A case of bacterial arthritis caused by Haemophilus paraphrophilus is presented. This is the first reported case of arthritis caused by this organism. Culturing joint fluid in blood culture bottles provides for bacteria that are slow growing or present in small numbers.

The value of biopsy in patients with monarticular juvenile rheumatoid arthritis of recent onset.

The histopathology of arthroscopic biopsy material from the knees of 8 patients with monarticular juvenile rheumatoid arthritis (JRA) of recent onset and of 4 control patients was examined using a histochemical method for acid alpha-naphthyl acetate esterase and an avidin-biotin-peroxidase complex method for different cell subtype-specific surface antigens. According to results of our prospective, single-blind study, nonspecific synovitis was observed in those biopsy samples obtained early in the course of disease. The samples were also characterized by cellular changes that are quite distinct from those described in patients with chronic rheumatoid synovitis. JRA must be considered the cause of symptoms if no orthopedic or infectious disease is found at arthroscopy in children with monarticular symptoms of recent onset and if nonspecific synovitis is observed in the histopathologic specimen. This pathologic description, however, does not correspond to that of classic rheumatoid synovitis. In our studies, we found that mononuclear cells displaying diffuse cytoplasmic esterase and surface Ia formed a large proportion of all inflammatory cells in situ. There were comparatively few activated Ia+ T cells and plasma cells. These observations suggest that exudative features and nonspecific cellular inflammation are prominent at onset of JRA. The immune response, in the form of immunocompetent T and B cells, seems to be more extensively involved in chronic JRA and may represent secondary features of the disease.

Treatment of juvenile rheumatoid arthritis with diclofenac sodium.

Diclofenac sodium was investigated in the treatment of juvenile rheumatoid arthritis (JRA). The pharmacokinetics of diclofenac in children aged 2-7 was assessed. Seven patients were included in a single-dose trial to determine plasma levels and renal elimination of diclofenac sodium. Venous blood samples were taken at 0, 0.5, 1, 2, 4 and 6 hours after administration of a 25 mg enteric-coated Voltaren tablet. Urine was collected before and 0-6 and 6-12 hours after tablet ingestion. Maximum concentrations ranged from 0.79 to 4.25 micrograms/ml, and were found between 0.5 and 2 hours. Renal elimination of total diclofenac ranged from 5.4 to 10.2% of the oral dose in 6 of the 7 patients. The youngest patient (2 years) had a lower elimination rate (2.25%) during the 12 hours observed. The values for children over 2 years corresponded to the range measured in adults. The pharmacokinetic study was followed by a placebo-controlled study with diclofenac sodium and acetylsalicylic acid (ASA) for 2 weeks in 45 hospitalized patients aged 3-15 years. The patients were randomly assigned to either: DS 2-3 mg/kg/day, microcrystallized ASA 50-100 mg/kg/day, or placebo matching diclofenac. Global evaluation of therapeutic efficacy showed improvement in 73% of the patients in the diclofenac group, in 50% of the ASA group and in 27% of the placebo group. A statistically significant difference between these groups was found (p less than 0.05). The sum of grades of joint tenderness decreased during the 2 weeks in 67% of patients in the diclofenac group, in 56% of the ASA group and in 36% of the placebo group.(ABSTRACT TRUNCATED AT 250 WORDS)

Fungal arthritis simulating juvenile rheumatoid arthritis.

Petriellidium boydii is often isolated from maduromycosis but has recently been associated with arthritis. A previously healthy 6-year-old boy developed chronic purulent arthritis of the knee after a bicycle accident. Culture of aspirate grew no pathogens and antibiotic treatment had no effect. Culture of synovial fluid grew P boydii, which responded initially to amphotericin but reappeared after six months. Subsequent treatment with miconazole was stopped after development of haematuria. The fungus was sensitive to ketoconazole, and treatment with this drug cured the infection. With the introduction of ketoconazole it is of practical importance to recognise fungal infections.

Dosage of salicylates for children with juvenile rheumatoid arthritis. A preliminary report.

The daily dosage of salicylates is traditionally very high for patients with juvenile rheumatoid arthritis. In order to achieve the optimal therapeutic effect, serum salicylate levels are kept at 30-35 mg/100 ml (2175-2540 mumol/l). The recommended daily dosage in the textbooks is about 100 mg/kg of body weight, and the reported dosage/m2 of body surface area has been 3.2 g/m2/day. These dosages are, however, too high in clinical routine. In the present investigation, 19 children were treated with salicylates for 15 days with daily check-ups of the serum salicylate levels. Seven of these children had symptoms of salicylate intoxication which corresponded closely to the serum salicylate levels. If the daily dosage of salicylates exceeds 3 g/m2 of body surface area, intoxication can be expected.